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06/03/2015 10:15 8387674 EMILS PAGE 10 • Appendix VI RECEIVED MONITORING SYSTEM CERTIFICATION JUN 0 3 2015 For Use By All Jurisdictions within the State of California Authority Cited:Chapter 6.7,Health and Safety Code;Chapter 16,Division 3,Title 23,Californl/ip C de of Reguill/a�tions This form must be used to document testing and servicing of monitoring equipment A separate car mcation or rapon iql ENTAL each monitoring system Control panel by the technician who Worms the work.A Copy of this form must be provid to 'DT44ealT omner/operator.The owner/operator must submit a ropy of this farm to the local agency regulating GST systams within 30 days of test its*. A. General information Facility Name: EMILS LIQUOR 8t SPORT S140P Bldg.No.: Site Andress: 1403 CALIFORNIA Sl', City: ESCALON Zip: 95320 Facility Contact Person: Contact Phone NO.: Make/Model of Monaodng System: GILDARCO EMC Data of Tesdng/Servring: 3/62015 B. Inventory of Equipment Tested/Certified Check the approerlats boxes to indicate ariecifit a ui ment ins ectedlserviced: Tank ID: 87 Tank Size: IIK Tank ID' Tank Size: 0 I vTank Gauging Probe, Model: MAO 2 ❑ In-Tank Gauging Probe. Model: 19 Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: 0 Piping Sump/Trench Senaor(s). Model: 208 ❑ piping Sumpl Trench Sensor(s). Model: ❑ Fill Sump Sersor(s). Model: ❑ Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Di lector. Model: 99 LD 2000 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Donation Model: ❑ Electronic Line Leah Detector, Model: 0 Tank Overfill/High-Level Sensor, Model: a Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and modal in Section E on Page 2). ❑ Other(spedlyequipment type and modal in Sedan E on Page 2). Tank ID: DIE Tank Shea: 4 K Tank ID: 91 Tank Size: 5 K 0 In-Tank Gauging Probe. Mpoel: MAG 2 Q M-Tank Gauging Probe. Model: MAO 2 0 Annular Space or Vault Sensor. Model: SAME VESSEL O Annular Space or Vault Sensor. Model: SAME VESSEL 19 Piping Sump/Trench Sensoria). Model: 208 0 Piping Sump/Trench Sermons). Model: 208 ❑ Fill Sump Sensor(s). Madel: II Fill Sump Sensor(s), Model: ID Mechanical Line Leak Detector. Model: FX-IV 14 Mechanical Line Leak Detector. Modal FX-1V ❑ Electronic We Leak Detector, Modal: ❑ Electronic Line Leak Detector. Model: ❑Tank Overfill f High-Laval Sensor. Model: ❑,Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on page 2). 0 Other(specify equipment type and modal in Section E an Page 2). Dispenser ID: Ill 2 Dispenser la: 3 / 4 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sansor(s). Model: M snearvalve(s). ® Shea-valve(s). 0 Dispenser Containment Floal(s)and Chaints). ® Dispenser Containment Floats)and Chain(s). Dispenser 10: Dispenser ID: ❑ Dispenser Containment Sensotc). Model: ❑ Dispansar Containment Sensor(s). Model: ❑ Shear Vatva(s). ❑ Shear Valve(s). ❑ 0130e05ef Containment Float(s)and Gnomic). ❑ Dispenser Containment Floats)and Chain(s), Dispenser ID: Dispenser ID: El Dispenser Containment 0 Dispenser Containment Sensor e , Model: Sensor(a). Model: ❑ Shear Vaive(s). ❑Shear Valve(s). ❑ Dispenser Containment Flost(s)and Chain(s). El Dispenser Containmeftt Float(s)and Chain(s). 'If the facility contains more tanks or dispansets,copy this farm. Include information for every tank and dispenser at the facility. C.CeniRC8116A-I certify that the equipment identified in this document was In5peCt4dls0rvided in accordance with the manufecturers' guidelines.Attached to this Certification Is Information(e.g.manufacturers'checklists)necessary to verify that this information is correct and a Plot Plan showing the layout Of monitoring equipment.Far any equipment capable Of generating such reports,1 have also attached a copy of the report;leheck air alar apply)' 0 system set-up 0 Alarm history region Techniclan Name(print): ZANE NIMMO Signature: Certification A28446 License No: G04--16776`----^^- No.: Testing Company A FORDA•TE$T - Phone No. (209)744-0173 Name: Testing Company Add,uss:' 4162 STREET GALT,rj g $Z LL— Date of Tesling'seMcmg: 5/6/2015 Monitoring System certification Page 1 of 4 2/21/07